PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: The water temperature in the bathroom was 54.1 degrees celsius.
Corrective Action(s): Please ensure that the water accessible to a person in care, from any source, is not heated to more than 49 degrees celsius.
Date to be Corrected: March 25, 2022
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Windex and WD40 were stored in an unsecured kitchen cabinet located under a sink and this area was accessible to persons in care.
Corrective Action(s): Please ensure to have a secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Date to be Corrected: April 26, 2022
STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: Three of 4 staff files did not have not have a valid criminal record check on file.
Corrective Action(s): It is a requirement that a Licensee obtains a valid criminal record check for an employee prior to working with vulnerable persons and existing employees must renew an existing criminal check every 5 years. Employees without a valid criminal record check must not work with persons in care. Please provide a Health and Safety Plan immediately for each employee that does not currently have a valid criminal record check.
Date to be Corrected: April 26, 2022
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: The Licensee’s policy and procedure requires that staff document that the results of PRN medications administered. PRN medication results were not recorded for 2 persons in care.
Corrective Action(s): Please ensure that staff implement the Licensee’s medication policies and procedures, which includes the recording the results of PRN medications administered. .
Date to be Corrected: April 26, 2022
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: The Licensee did not have evidence of reviewing policies and procedures during 2021.
Corrective Action(s): Please ensure that policies and procedures are reviewed and, if necessary, revised once per year.
Date to be Corrected: April 26, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: An unlabelled plate of food covered in cling wrap was stored in the kitchen’s refrigerator and a second unlabelled plate of food covered in cling wrap was stored in the refrigerator’s freezer. Two bags of biscuits and cans of food past their best before dates were stored in the emergency supplies bin.
Corrective Action(s): Please ensure that all food is safely stored.
Date to be Corrected: April 26, 2022.
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: The Licensee’s menu included a list of snacks that persons in care could choose from; however, some snacks included on this list only included foods from 1 food group.
Corrective Action(s): A licensee menu must ensure that persons in care are provided with 2 snacks per day, with each snack containing at least 2 food groups.
Date to be Corrected: April 26, 2022.
PROGRAM: 38010 - RCR s.55(1)(a)(i) - A licensee, other than a licensee who provides a type of care described as Hospice, must (a) provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities (i) suitable to the needs of the persons in care.
Observation: Two PICs were charged for fuel costs during a recreational outing.
Corrective Action(s): PICs must be provided with program of planned activities without charge. Please ensure that PICs are not charged for ongoing activities that take advantage of opportunities in the community.
Date to be Corrected: April 26, 2022
RECORDS AND REPORTING: 39570 - RCR s.90(1) - A licensee must maintain separate financial records for each community care facility, made in accordance with generally accepted accounting practices.
Observation: An entry had been made into a ledge kept for the financial records of persons in care; however, no corresponding receipt was found.
Corrective Action(s): The Licensee must keep a record, in accordance with accounting practices, of all purchases for persons in care. Licensing must be able to audit these records to determined compliance with s.90(1) requirements.
Date to be Corrected: April 26, 2021
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